Current global surgery rules for Medicare have been in place since 1992, and most other payers follow Medicare guidelines. Sometimes, however, we still get questions. Here’s our guidance.

Q. What is Medicare’s global surgery policy?

A. In 1992, Medicare instituted its global surgery policy as part of physician payment reform. It pays a single global fee for all necessary services furnished by the surgeon before, during, and after the procedure. The Medicare Claims Processing Manual (MCPM) Chapter 12 identifies services that are and are not part of the global package (https://www.cms.gov/files/document/medicare-claims-processing-manual-chapter-12 ).

Sections §40.1.A and §40.1.C describe the components of a global surgery package. These include, among others, the following:

• Preoperative visits after the decision is made to operate. This is generally construed to begin the day before the day of surgery for major procedures. For minor procedures, visits by the same physician on the day of a minor surgery are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.
• Intraoperative services that are normally a usual and necessary part of a surgical procedure.
• Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery.
• All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room.
• Supplies, except for those identified as exclusions.
• Services by other physicians are not included in the global fee except as otherwise excluded.

Q. What services are excluded?

A. Services excluded from the global surgical package and reimbursed separately are described in §40.1.B. They include the following:

• For major surgical procedures, the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery is payable. The initial evaluation is always included in the allowance for a minor surgical procedure.
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.
• Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery.
• Diagnostic tests.
• Clearly distinct surgical procedures during the postoperative period that are not reoperations or treatment for complications.
• Staged procedures when the decision to stage the procedure is made prospectively or at the time of the first procedure.
• If a less extensive procedure fails and a more extensive procedure is required, the second procedure is payable separately.
• Treatment for postoperative complications that require a return to the operating room (OR).
• Services by other physicians are not included in the global fee except as otherwise excluded.

Q. Does “other physicians” include my partners?

A. Probably not. The MCPM instructions for global surgery include a reference for physicians in group practice. MCPM Chapter 12, §40.2 instructs that physicians of the same specialty in a group practice function collectively as the “surgeon” and should abide by the global surgery rules. In this context, an associate is not distinguished from the performing physician and inherits the limitations imposed by the global surgery policy.

Q. How does “return to the OR” work?

A. Reoperations that are required following a failed retinal detachment repair or other procedure, which require a return to the OR to be performed, are separately payable. For example, a pneumatic retinopexy is performed for retinal detachment but fails, so the surgeon takes the patient back to the OR in a hospital for a scleral buckling procedure.

Sometimes, the OR is not located in an ambulatory surgery center or hospital outpatient facility but is a “laser suite” in the physician’s office. Medicare’s regulations state, “An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite; it does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit” (https://www.cms.gov/files/document/medicare-claims-processing-manual-chapter-12 ). For example, the patient is treated for a peripheral retinal tear with laser in the office, but shortly thereafter the tear extends beyond the coagulated tissue; the surgeon then performs a pneumatic retinopexy in the office laser suite.

Treatment of postoperative complications that do not require a return to the OR are part of postoperative care and not separately reimbursed. For example, in-office intravitreal injection of triamcinolone during the postoperative period of a complex retinal detachment surgery does not require a laser suite, and does not require an OR, so it is postoperative care.

Q. Are diagnostic tests always separately payable?

A. Although tests during the postoperative period are explicitly not part of the global surgery package, there are subtle nuances. Tests to confirm the expected outcome of a procedure are part of postoperative care. For example, extended ophthalmoscopy following retinal detachment repair is not separately reimbursed if performed to verify a successful outcome. In contrast, a diagnostic test to evaluate a failed procedure and help plan another surgery is covered, as is a test on the fellow eye to plan a subsequent surgery. RP